Reception: Medication + Diabetes Annual Review

Monitoring your diabetes is key to make sure you reduce the chance of complications (negative outcomes) and maintain good control.

This is done via an annual diabetes review at the practice where we look at a number of parameters.

What do I need to do?

Receive text or prescription note from us requesting a review
Follow the instructions on the note. If it requests you book in with a nurse to complete a blood test, urine sample, blood pressure & examination then please book in for this PRIOR to completing the form below
Complete the form below
Await response from us (this will be via text, letter or phone call)

XPERT: Education programs for Type II Diabetes

CLMP Fitness Club: Help control your condition with physical activity with our team

Further information on diabetes

This form is for NON-urgent queries. Your information will be assessed and you will be contacted via text, letter or phone call to explain the outcome. Please do not contact reception prior to 1 working day as they will be unable to give you an update. If you feel your query is urgent call reception on 01926 331401. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Reception: Medication + Diabetes Annual Review

Full Name:

Date of Birth (DD/MM/YYYY)

Contact Number (Preferably Mobile)

Do you have any concerns or side effects from your medication?

If yes - Please explain what side effects or issues you have experienced

Do you know when and how to take your medication?

Please record your most recent home/hospital/pharmacy blood pressure:

Do you take an over the counter, herbal remedies or specialist medication? If no write: NO. If yes, please state the name and dose of these medications.

Are you happy for the doctor to update your medication review date now?

Height In cm or inches please specify

WeightIn kg or Stone (please specify)

How many units of alcohol do you consume per week?

What is your current treatment plan?

What monitoring do you if any at home?

Have you noticed any loss of sensation?

Privacy Protection

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This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Clarendon Lodge Medical Practice • Clarendon Lodge, 16 Clarendon Street, Leamington Spa, Warwickshire, CV32 5SS.

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